1. Fractures of the Foot SWOTA 2010 Richard Miller MD University of New Mexico

2. What does the Hawkin’s sign signify? A. Avascular necrosis is probably present A. Avascular necrosis is probably present B. Avascular necrosis is probably absent B. Avascular necrosis is probably absent C. Surgery is urgent C. Surgery is urgent D. An MRI is indicated D. An MRI is indicated E. There is a nonunion E. There is a nonunion

3. Healthy 34 year old with chronic foot pain, suddenly worse after twisting injury A. Cast nonweightbear A. Cast nonweightbear B. Cast weightbear B. Cast weightbear C. ORIF C. ORIF D. Orthotic D. Orthotic E. Electrical stimulation E. Electrical stimulation

4. Overview of foot fractures Overview of foot fractures Talus Talus Calcaneus Calcaneus 5 th metatarsal 5 th metatarsal Lisfranc, tarsal-metatarsal injury Lisfranc, tarsal-metatarsal injury

5. Evaluation of Foot Injuries History History Physical exam Physical exam Proper radiographs Proper radiographs AP, lateral, oblique foot and/or ankle AP, lateral, oblique foot and/or ankle

6. Look at Everything, Not Just the Obvious

7. Management of Foot Fractures Reduce the fracture Reduce the fracture Splint Splint Rest (crutches) Rest (crutches) Elevate Elevate

8. Urgent Operative Treatment Open fractures Open fractures Compartment syndrome Compartment syndrome Impending skin breakdown Impending skin breakdown

9. Goals of Treatment Painless Painless Mobile Mobile Functional, bear and transfer weight during the gait cycle Functional, bear and transfer weight during the gait cycle Shoeable Shoeable Well aligned foot Well aligned foot

10. Multiple Trauma Delayed Diagnosis of Foot Fractures Maintain a high index of suspicion for foot fractures Maintain a high index of suspicion for foot fractures Obtain and review X-Rays in the presence of pain, swelling, bruising, deformity Obtain and review X-Rays in the presence of pain, swelling, bruising, deformity Foot fractures often the source of persistent disability after multiple trauma Foot fractures often the source of persistent disability after multiple trauma

11. Tibia, Femur Fractures Lateral Process of Talus

12. Calcaneus Fractures Fall or MVA Fall or MVA Rule out spine injury Rule out spine injury Intraarticular displacement Intraarticular displacement Flattening of Bohler’s angle Flattening of Bohler’s angle

13. Joint Depression, Tongue Type

14. CT Classification

15. What is the classification? 1. joint depression 1. joint depression 2. tongue 2. tongue 1. II A 1. II A 2. II B 2. II B 3. III AB 3. III AB

16. Calcaneus Fractures Intraarticular displacement = arthritis Intraarticular displacement = arthritis Lateral body widening Lateral body widening Abutment with fibula Compression of peroneal tendons and sural nerve Shoe wear difficulty

17. Calcaneus Fracture Treatment Operative vs. nonoperative treatment is controversial Operative vs. nonoperative treatment is controversial Restoration of joint and Bohler’s angle Restoration of joint and Bohler’s angle Persistent pain and functional limitation common Persistent pain and functional limitation common

18. Talus Neck Fracture Classification Hawkins I: nondisplaced I: nondisplaced II: displaced subtalar joint II: displaced subtalar joint III: displaced at ankle and subtalar joint III: displaced at ankle and subtalar joint IV: displaced at talonavicular joint IV: displaced at talonavicular joint

19. What is the Classification? 1 Hawkins I 1 Hawkins I 2 Hawkins II 2 Hawkins II 3 Hawkins III 3 Hawkins III 4 Hawkins IV 4 Hawkins IV

20. Talus Neck Fractures Nondisplaced fractures may be treated with nonweightbearing cast (6-8 weeks), Nondisplaced fractures may be treated with nonweightbearing cast (6-8 weeks), followed by walking boot and motion followed by walking boot and motion Surgical ORIF for displaced fractures

21. Type III Talar Neck Fractures Urgent ORIF when skin compromise is present such as type III fracture Urgent ORIF when skin compromise is present such as type III fracture

22. ORIF Displaced Talus Neck Fractures

23. Hawkins Sign 6-8 Weeks is Good and Represents Intact Blood Supply

24. Tarsal-Metatarsal Injuries (Lisfranc Injury)

25. Normal Oblique X-Ray

26. Tarsal-Metatarsal Injury Closed reduction Closed reduction Rule out compartment syndrome Rule out compartment syndrome Open reduction and internal fixation when skin condition allows Open reduction and internal fixation when skin condition allows

27. Open Reduction Internal Fixation

28. 5 th Metatarsal Base Fractures

29. Tuberosity (Dancer’s) Fracture Walking cast boot Walking cast boot Minor degrees of displacement acceptable Minor degrees of displacement acceptable ORIF or excision for rare nonunion ORIF or excision for rare nonunion

30. Jones Fracture Metaphyseal-Diaphyseal Junction Higher percentage of nonunion Higher percentage of nonunion Treat with nonweightbearing cast X 6 weeks followed by walking cast Treat with nonweightbearing cast X 6 weeks followed by walking cast Consider ORIF for athlete or signs of stress fracture on presentation Consider ORIF for athlete or signs of stress fracture on presentation

31. Intramedullary Screw

32. Complications of Foot Injuries Nonunion of fractures Nonunion of fractures Posttraumatic arthritis Posttraumatic arthritis Complex regional pain syndrome Complex regional pain syndrome Stiffness Stiffness Swelling Swelling Deformity Deformity Deep venous thrombosis Deep venous thrombosis

33. Thank You for Listening Questions? Discussion

34. A) B) C) D) E) Worst Bad OK Good Best Worst Bad OK Good Best Helpfulness of Material COMMENTS Please SWOTA : 2010 Resident Course - Fundamentals of Fracture Care Foot Fractures

35. A) B) C) D) E) Worst Bad OK Good Best Worst Bad OK Good Best Quality of Presentation COMMENTS Please SWOTA : 2010 Resident Course - Fundamentals of Fracture Care Foot Fractures